When an authorized employee who applied a lockout or tagout device is not available to remove it, the authorized employee who intends to remove the lock must complete this form to ensure that the requirements of 29 cfr 1910. Machine specific lockout tagout procedure template. Not to be sold or published on for profit websites. This sample hazardous energy control program has been prepared by safe state to provide assistance for compliance with osha standard 1910. Always be sure all lockouttagout devices are compatible with the environment in which they will be used i. Employees authorized to perform lockout shall be certain as to which switch, valve, or other energy isolating devices apply to the equipment being locked out. It is specific both to the equipment or system and to the scope of work. Never attempt lockouttagout procedures unless you have been trained and certified by your employer under an approved energy control program. General this document is to establish minimum guidelines to assist with the safety and health of personnel who may be required to work on. Lockouttagout the placement of lockout and tagout devices on an energy isolating device, according to the established procedures of this policy see sections iv and v.
The fund is providing this template, which members can customize to. Lockout form a preprinted form to fill out for group loto procedure to document and communicate isolation and repair status lockouttagout specific practices and procedures to safeguard employees from the unexpected energizing or startup of machinery and equipment or the release of hazardous energy during service or maintenance activities. In this article, well look at the basics of lockouttagout and loto safety. Simply stated, an energy control procedure is a written procedure that identifies allthe steps a worker must take to. Lockout and tagout policy for enter company name purpose. Departments are responsible for adopting and implementing this control of hazardous energy program lockout tagout. The loto procedure fulfills the following purposes. The osha control of hazardous energy lockouttagout standard 29 cfr 1910. Enter your official identification and contact details. Ttool c sample lockout tagout safety permitool c sample lockout tagout safety permit safety permit permit issued to. Lockout tagout lockout energy source isolation placards document and show visual procedures to control, isolate, and lockout energy sources as required by osha. Why do i need to be concerned about lockout tagout. Present information in a standardized, yet customized, easytofollow format.
When done properly before equipment service or maintenance, lockouttagout procedures control hazardous energy and protect workers from harm. It does not necessarily reflect the views or policies of the u. Lockouttagout energy control program dalhousie university. Osha lockout tagout assessment worksheet selfexplanatory assessment worksheet from osha. Lockouttagout compliance guide and checklist scope.
Lockout tagout safety program agricultural safety and health. This form is used to identify equipment machinery systems that require lockout procedures. The way to complete the online sample lockout tagout template on the internet. A safety lockout procedure form template is provided in appendix 1. Oshas standard on the control of hazardous energy lockout tagout, found in title 29 of the code of federal regulations cfr part 1910. Electrical end of cord plastic clamshell and padlock stop. If you are not sure how, contact your supervisor for instructions. Supervisor and employee lockouttagout annual evaluation form. It shall be used to ensure that the machine or equipment is. When machines or equipment are being prepared for service or maintenance, they often contain some form of hazardous energy that can.
Print full color with photo images on a visual sign placard and place the. All maintenance personnel shall be provided with a good lock. Control of hazardous energy guideline lockouttagout i. Yes m no m na m was the procedure form properly filled out. This procedure establishes the minimum requirements for the lockout of energy isolating devices whenever maintenance or servicing is done on machines or equipment. Control of hazardous energylockout and tagout effective date.
Ttool c sample lockouttagout safety permitool c sample lockouttagout safety permit safety permit permit issued to. The advanced tools of the editor will direct you through the editable pdf. Dalhousie uses various forms of energy isolating devices to physically prevent the transmission or release of. Lockout form a form indicating the procedure to be followed to lock out. Notify production supervisor and all affected personnel.
When an authorized employee who applied a lockout or tagout device is not available to remove it, the. Contract service and maintenance name of your company and contractors must be aware of their respective lockout tagout procedures before the contractor does onsite work. Lockout form a preprinted form to fill out for group loto procedure to document and communicate isolation and repair status lockouttagout specific practices and procedures to safeguard. Identify which type of energy is present and requires. Template for control of hazardous energy procedure lockout. This policy is established to protect university employees from the serious injuries that. Lockout tagout fact sheet employees need to be trained to ensure that they know, understand, and follow the applicable provisions of the hazardous energy control procedure. This document provides an over view of oshas control of hazardous energy standard along with a template for a basic written lockouttagout procedure. Lockout form a preprinted form to fill out for group loto procedure to document and communicate isolation and repair status. Lockout tagout the placement of lockout and tagout devices on an energy isolating device, according to the established procedures of this policy see sections iv and v. Electricity is the only form of potentially hazardous energy. Departments are responsible for adopting and implementing this control of hazardous. Lockout tagout annual procedure inspection certification. Lockout tagout form in word and pdf formats page 2 of 2.
Control of hazardous energy occupational safety and. A loto procedure is required for all complex lotos. It documents the scope of work permitted under the loto. The most vital element of the lockout tagout program is the energy control procedure. It should be expanded, personalized and tailored to your companies, places of business or worksites. The advanced tools of the editor will direct you through the editable pdf template. Control of hazardous energy guideline lockouttagout. I hereby certify the periodic inspection for compliance with lockouttagout standards on this. Template for control of hazardous energy procedure. This will include some basic definitions, relevant osha regulations and informational. Users must revise this generic form as necessary to fit their operations. Sample lockout tagout template fill out and sign printable. The content is arranged in a table format and can be edited in microsoft word. Apply lockouttagout devices lockout all energy isolating devicespoints, tag placed on lockout device contains required information, group lockout is usedif more than one employee is involved 6.
Be sure to modify them to make them specific to your company or facility bloodborne. Review procedural responsibilities with all authorized employees, document on training form, attach to this sheet this form provided courtesy of. A loto procedure is a formal document detailing all the steps required to establish the lockout. Lockout tagout loto annual inspection and training assessment checklist. Operate equipment controls to verify that the equipment is deenergized. Environmental health and safety main office 6 eisenhower parking deck university park, pa 168022116 phone. Lockouttagout employee verification form continued 4. Lockouttagout lockout energy source isolation placards document and show visual procedures to control, isolate, and lockout energy sources as required by osha. Lockout tagout annual procedure inspection certification form. This procedure establishes the minimum requirements for the lockout of energy isolating devices whenever maintenance or servicing. Ensure the completion the lockouttagout equipment specific procedures form. Lockouttagout periodic inspection form machineequipment name.
Deenergize equipment and lockout or tagout energyisolating devices. This material was produced under a susan harwood training grant from the occupational safety and health administration, u. Below are model program templates, checklists, logs, and other useful documents in an editable format ms word. General this document is to establish minimum guidelines to assist with the safety and health of personnel who may be required to work on any type of equipment capable of being energized or harboring stored energy. This will be achieved through the implementation of wsns lockouttagout procedures to be followed by all staff and. Machine specific lockout tagout procedure template fill. B if so, have employees been retrained when job assignments, machines, equipment or processes have changed. Control of hazardous energy procedure lockouttagout in accordance with wisconsin safety and professional services chapter sps 332 and osha 29 cfr 1910.
Department of labor, nor does mention of trade names, commercial products, or organizations imply endorsement by. Never loan or share your lock, combination, or key with anybody else. Hazardous energy control lockouttagout program template. Lockouttagout fact sheet employees need to be trained to ensure that they know, understand, and follow the applicable provisions of the hazardous energy control procedure. Fill out, securely sign, print or email your machine specific lockout tagout procedure instantly with signnow. C how to write a machineequipmentspecific lockouttagout procedure. Grantee materials by topic occupational safety and. Lockout the equipment following the lockout procedure at the wet transfer on rolls cabinet local disconnect on the north wall. Grantee materials by topic occupational safety and health. Pub3000, chapter 18, work process n addresses loto procedures. The lock shall have the individual workers name and other identification on it. Use this form to document an inspection of a written lockout or tagout procedure. Employees can be seriously or fatally injured if machinery they service or maintain unexpectedly energizes, starts up, or releases stored energy.
A sample lockouttagout procedure a good lockouttagout procedure, at a minimum, should contain the following elements. After completing step 1, shut down equipment, if running, as trained. Lockouttagout university of arizona risk management and safety. The most vital element of the lockouttagout program is the energy control procedure. Lockouttagout loto procedure template electrical safety.